Nevada - in Forma Pauperis Affidavit Updated Form

1 2 3 4 5 6 7 8 9 Case No. ________________________ 10 Dept. No. ______ 11 12 Plaintiff, 13 vs.
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 month; ( ) I am presently employed by _______________________ and work ____ hours per week; Defendant(s). STATE OF NEVADA COUNTY OF } } } / AFFIDAVIT OF DEFENDANT IN SUPPORT OF APPLICATION TO PROCEED IN FORMA PAUPERIS IN THE NINTH JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA IN AND FOR DOUGLAS COUNTY
I,________________________________, the above named Defendant, proceeding in propria persona, being first duly sworn, depose and say under the pains and penalties of perjury, as follows: ( ) I have insufficient income to pay the filing fees and court costs to defend this action and to pay for my necessary household living expenses; ( ) I am presently insolvent as my liabilities exceed the value of my assets; ( ) I am presently unemployed; ( ) I receive unemployment assistance in the amount of $_____ per week; ( ) I receive social security or other government benefits in the amount of $______ per
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( ) I receive $______ per month in regular after tax income from my employer. ( ) My household consists of ____ persons which includes myself _____________________ ________________________________________________________________________________; ( ) All of my disposable income is used to maintain myself and my household; ( ) I have no stocks, bonds, or other unexempt investment accounts that can be liquidated to pay filing fees and court costs to defend this action; ( ) I have no funds in a savings account or similar account available to me to pay filing fees and court costs to defend this action; ( ) I have no unencumbered property or unnecessary unexempt assets, pursuant to NRS 21.090, that can be sold or otherwise converted into cash to pay the filing fees and court costs to defend this action. ( ) I am unable to receive assistance from family or friends to defend this action. The following represent my total monthly expenses: Rent / Mortgage Payment Utilities Food Clothing Health Insurance Out of Pocket Medical Car Payment Inrance Fuel Expenses Other Necessary Expenses: __________________________________________ __________________________________________ __________________________________________ __________________________________________ TOTAL MONTHLY EXPENSES
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0.00 $______________ 0.00 $______________ 0.00 $______________

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1 2 3 4 5 6 Defendant 7 8 9 by ______________________________ 10 this ___ day of ______________, 20___. 11 12 13 14 15 16 Dated this ____ day of ___________________, 20___. 17 18 Defendant 19 20 21 22 23 24 25 26 27 28 AFFIRMATION I hereby affirms pursuant to NRS 239B.03 that the foregoing does not contain the social security number of any person, or other personal information as defined by NRS 603A.040. _________________________________ NOTARY PUBLIC SUBSCRIBED and SWORN to before me, a Notary Public, I hereby requests that the Court permit me to proceed in forma pauperis pursuant to NRS 12.015. Dated this ____ day of ___________________, 20___.
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
CERTIFICATE OF SERVICE Pursuant to NRCP 5(b) I certify that on this ____ day of ____________, 20____, I deposited for delivery the foregoing document described as Affidavit of Defendant in Support of Application to Proceed in Forma Pauperis for service by placing an original or true copy thereof in a sealed envelope placed for collection and mailing on said date addressed as follows: Address of Plaintiff or Plaintiffs Counsel:
________________________________ Signature ________________________________ Print Name
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Nevada - in Forma Pauperis Affidavit Updated Form

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1 2 3 4 5 6 7 8 9 Case No. __________________ 10 Dept. No. 11 12 Plaintiff, 13 vs.

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